SB68,1,31An Act to create 49.4713 of the statutes; relating to: premium and 2cost-sharing assistance for health plans through the Medical Assistance 3program.

Analysis by the Legislative Reference Bureau

Currently, the Department of Health Services (DHS) administers the Medical Assistance (MA) program, which is a joint federal and state program that provides health services to individuals who have limited financial resources. Some MA services are provided through programs that operate under a waiver of federal Medicaid laws, including services provided through the BadgerCare Plus (BC+) and BadgerCare Plus Core (BC+ Core) programs. Certain parents and caretaker relatives and certain childless adults with incomes of not more than 100 percent of the federal poverty line (FPL), before a 5 percent income disregard is applied, are currently eligible for BC + or BC+ Core benefits.

The federal Patient Protection and Affordable Care Act (ACA) creates American health benefit exchanges through which individuals purchase coverage under a qualified health plan, which is health insurance that meets certain criteria under the ACA. Generally, under the ACA, individuals with household incomes between 100 and 400 percent of the FPL who purchase certain qualified health plans through the American health benefit exchanges (exchanges) qualify for income tax credits to subsidize some of the cost of purchasing the qualified health plan. Qualified health plans may require cost-sharing, such as deductibles or copayments, and the ACA provides certain individuals who purchase specific plans through an exchange with reductions in cost-sharing. The ACA also provides financial assistance through an enhanced federal medical assistance percentage (FMAP) to states that expand their Medicaid programs. The enhanced FMAP under the ACA applies to certain newly eligible individuals whose family income level is up to 133 percent of the FPL.

This bill requires DHS to create a premium assistance program to pay premiums and any cost-sharing amounts to assist eligible parents or caretaker relatives and eligible childless adults in purchasing coverage through a qualified health plan offered through an American health benefit exchange. Eligible parents or caretaker relatives and eligible childless adults are those who would otherwise be eligible for BC+ or BC+ Core except that their family income exceeds the eligibility requirements for BC+ or BC+ Core but does not exceed 133 percent of the FPL. The bill also requires that DHS ensure that individuals who become eligible for BC+ or BC+ Core while having coverage under a qualified health plan that is offered by an insurer that also offers a managed care plan for the MA program are allowed to transition from the qualified health plan to the managed care plan. DHS must also ensure that eligible parents, caretaker relatives, and childless adults are allowed to enroll in qualified health plans throughout the year and not solely during open enrollment periods determined by the federal government.

DHS is required to submit a request for any necessary approval to the federal government to implement the premium assistance program and to qualify for the highest available enhanced FMAP for eligible childless adults, parents, and caretaker relatives in the premium assistance program, childless adults eligible for BC+ Core, and, if considered newly eligible under the ACA, parents and caretaker relatives eligible for BC+. If DHS does not receive federal approval for the premium assistance program or does not qualify, or ceases to qualify, for an enhanced FMAP, DHS must submit a cost analysis to the Joint Committee on Finance (JCF). If JCF approves of eliminating the premium assistance program, DHS is not required to implement the premium assistance program.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB68,2,5249.4713Premium assistance program.
(1)Definitions. (a) "Eligible 3childless adult" means an individual who is eligible under s. 49.45 (23) (a) except that 4his or her family income exceeds the income level described in s. 49.45 (23) (a) but 5does not exceed 133 percent of the poverty line.

SB68,3,31(b) "Eligible parent or caretaker" means an individual who satisfies the criteria 2in s. 49.471 (4) (a) 4. a. and whose family income exceeds the income level described 3in s. 49.471 (4) (a) 4. b. but does not exceed 133 percent of the poverty line.

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(d) "Qualified health plan" means a plan defined in 42 USC 18021 (a) that is 7offered through any American health benefit exchange, as described in 42 USC 818031, that is operating in the state.

SB68,3,139(2)Premium and cost-sharing assistance; managed care plans. (a) The 10department shall establish a premium assistance program to pay premiums and any 11cost-sharing amounts from moneys allocated for the Medical Assistance program for 12any eligible childless adult and any eligible parent or caretaker to purchase coverage 13under a qualified health plan.

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(b) The department, and the office of the commissioner of insurance if 15necessary, shall ensure that an individual who becomes eligible for a program under 16s. 49.45 (23) or s. 49.471 while having coverage under a qualified health plan that 17is offered by an insurer that also offers a managed care plan for the Medical 18Assistance program may transition from the qualified health plan to the managed 19care plan.

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(c) The department, and the office of the commissioner of insurance if 21necessary, shall ensure that eligible childless adults and eligible parents and 22caretakers are allowed to enroll in qualified health plans throughout the year and 23not solely during an open enrollment period determined by the federal government.

SB68,4,624(3)Federal approval. (a) The department shall submit any amendment to the 25state medical assistance plan, request for a waiver of federal Medicaid law, or other 1request for other approval required by the federal government to implement the 2premium assistance program under sub. (2) and to qualify for the highest available 3enhanced federal medical assistance percentage for eligible childless adults and 4eligible parents and caretakers under this section, for individuals described under 5s. 49.45 (23) (a), and for any individuals described under s. 49.471 (4) (a) 4. that are 6considered newly eligible under 42 USC 1396d (y) (2) (A).

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(b) If the department does not receive federal approval for a premium 8assistance program substantially similar to sub. (2) or does not qualify, or ceases to 9qualify, for an enhanced federal medical assistance percentage requested under par. 10(a), the department shall submit to the joint committee on finance a fiscal analysis 11comparing the cost of the premium assistance program to only providing benefits 12under s. 49.45 (23) and s. 49.471. If the joint committee on finance approves of 13eliminating the premium assistance program, the department is not required to 14implement the premium assistance program under sub. (2).